Wiki New Patients

[KaylaRieken]

Every time we see a new patient we receive referral records. The doctors obviously use these for the HPI. Can they also use this in the data review for 2 points for reviewing records or would this be considered double dipping? I need some clarification on this.

Thanks!!

 

[Pam Warren]

You can't use record review for the HPI. The HPI is the documentation of the provider asking the patient in real time, about the history of the illness/condition that is being assessed at that encounter. The ROS is a overview by the provider of related or unrelated symptomology, either asked to the patient, or validated from a form that the patient completes and the physician validates for accuracy. The provider would also need to validate any PFSH, at that visit, and not just copy/paste the information from a previous provider's note. I would not recommend that a provider use another physicians notes to formulate their own HPI.

You can use the record reveiw to calculate your level of data, but when you do this your physician must state not only that the records were reveiwed, but he/she must indicate anything that would be relevant or pertinent to the current visit. Simply stating' records were reveiwed' is not sufficient.